嘉義長庚 骨科部 沈世勛. introduction skeletal trauma accounts for 10-15 % of all...
TRANSCRIPT
PEDIATRIC FRACTURES
嘉義長庚 骨科部沈世勛
Introduction
Skeletal trauma accounts for 10-15 % of all childhood injuries
Immature skeleton differs from that of the adult
Vary in different age groups
Periosteum
Thicker Greater osteogenic potential Callus formation An effective internal restraint in close reduction
Injury pattern
Buckle
Plastic Deformity
Greenstick
Injury pattern
Patterns of fracture – Variations with age
Physis
Salter-Harris fracture type
Changes in treatment philosophy Blount’s Non-operative axioms –
mid-1950s
Complications with operation intervention
The trend toward minimal invasion
Factors creating the trend toward operative intervention Improvement in technology
Rapid healing
Minimal hospitalization
The perfect result
Fractures about the elbow
“Pity the young surgeon whose first case is a fracture around the elbow”
~ Mercer Rang
With an understanding of the anatomy and adherence of a few basic principles, treatment of such fractures can be straightforward
Anatomy (CRITOE)
Radiographs interpretation
Radiographs interpretation
Baumann’s angle
Normal range 64 to 81 degrees
Difference > 5 degrees should not be accept
Fat pad sign
Supracondylar fracture
Most common type of elbow fracture in children and adolescents 50% to 70%
Most frequently in children between the ages of 3 and 10 years
High incidence of residual deformity and potential for neurovascular complications
Mechanism of injury
Extension or flexion force on the distal humerus
Extension type 95% to 98% Fall on an
outstretched hand
Mechanism of injury
Flexion type 2% to 5% Direct blow on the
posterior aspect of a flexed elbow
Classification
Modified Gartland’s classification Type I: non-displaced or
minimal displaced
Type II: angulation of the distal fragment, one cortex remains intact
Type III: complete displaced
Type IV: multidirectional instability
Treatment
Type I fracture Long arm cast – 3 weeks
Type II fracture Close reduction plus percutaneous
pinning (or long arm cast ) Type III fracture
Close reduction plus percutaneous pinning
Pin configuration
Biomechanical studies Crossed pins are stronger in torsion than a lateral
lateral-entry construct
A systemic review (crossed vs. lateral only) 1.84 times – iatrogenic nerve injury 0.58 times – loss of reduction
Recent prospective studies – no difference in loss of reduction or iatrogenic nerve injury
Medial pin
Placed with the arm in extension
Sweeping the soft tissue posteriorly away from the medial epicondyle
Remove medial pin if an iatrogenic ulnar nerve injury noted postoperatively
Immobilization after pinning Immobilized in 30 to 60 degrees of
flexion in a posterior splint or bivalved cast
Return in 7 to 10 days to check for maintenance of reduction
Pins are removed and immobilization is discontinued in 3 to 4 weeks after the injury
Vascular injury
2% to 38%
manipulation and close observation Failed to provided distal circulation
immediately CR + pinning
Considered surgical exploration and repair if the limb remains ischemic
Peripheral nerve injury
10% to 15% Extension type – anterior interosseous
nerve (AIN) Posterolaterally displaced – median
nerve Posteromedially displaced – radial nerve Ulnar nerve – iatrogenic injury
If function is not return within 8 to 12 weeks, NCV and EMG should be given to ensure the nerve has not been transected
Volkmann’s Ischemic Contracture Compartment syndrome
Improved management Incidence decreased
Floating elbow may be at increased risk
A supracondylar fracture associated with a compartment syndrome is generally best managed by closed reduction and pinning.
Malunion
Cubitus varus is more common
Functional problems are uncommon with either deformity
Cosmetic disturbance
Lateral condyle fracture
The second most common operative elbow injury in children
May be difficult to diagnose and have a propensity for late displacement
high complication rate
Mechanism of injury
Fall on an outstretched arm A varus stress that avulses the lateral
condyle A valgus force in which the radial head
directly pushes off the lateral condyle
Diagnosis
The hallmark radiographic finding is the posteriorly base Thurston-Holland fragment in lateral view
Oblique view or arthrograms are helpful in identifying minimal displaced fractures
Classification
Milch’s classification
Classification
Jakob classification
Stable type
Unstable type
Classification
According to displacement Non-displaced: < 2 mm Minimally displaced: 2-4 mm Displaced: > 4mm
Treatment
Non-displaced fracture Cast immobilization Close follow-up
Minimally displaced fracture Cast immobilization
Late displacement delay union or nonunion
Close reduction and pinning arthrography intraoperatively
Treatment
Displaced fracture Open reduction and pinning
Posterolateral approach possibility of injury to blood supply
Lateral approach judge the reduction of the articular surface
Lateral condyle nonunion
The most frequent problematic complication
Fracture constant exposed to synovial fluid
Lateral condyle has a poor blood supply
Constant motion at the fracture site from the pull of the wrist extensors of the distal fragment
Lateral condyle nonunion
A nonunion can present with one of three scenarios Painful nonunion
Osteosynthesis ± bone grafting
Cosmetic unacceptable valgus deformity Corrective osteotomy
Tardy ulnar nerve palsy Anterior transposition
Transphyseal fracture
Most common in children younger than 2 years
Result from child abuse (up to 50%) or birth trauma
Diagnosis can be challenging Often misdiagnosed as elbow dislocation or
lateral condyle fracture Ultrasound, MRI, arthrogram can be helpful
Transphyseal fracture
Mechanism of injury
Depends on the age of the patient Newborns and infants
Rotatory or shear force associated with birth trauma or child abuse
Older children Usually a hyperextension force from a fall
on an outstretched hand
Different diagnosis
Elbow dislocation Abnormal radial head-capitellum relationship Rarely occurred in this age group
Lateral condyle fracture Oblique radiographs, arthrogram, MRI Metaphyseal fragment are displaced laterally
Supracondylar fracture Fracture usually at the level of the olecranon
fossa
Treatment
Simple immobilization Cubitus varus occurs frequently
Close reduction and pinning
Medial condyle fracture
Around 50% are associated with elbow dislocation
Usually occur between 7 to 15 years of age
Account for approximately 10% of all children’s elbow fracture
Mechanism of injury
A valgus stress producing traction on the medial epicondylar trough the flexor muscle
Treatment
Nonsurgical treatment, even displaced
Immobilization – 1 to 2 weeks
Treatment
Indication for surgical treatment Absolute indication
Fragment incarcerated in joint Open fracture Gross elbow instability
Relative indication High-demand, over head athlete, such as
a pitcher
Complications
Stiffness Most common complication Immobilization no more than 3 weeks to
avoid complication
Ulnar nerve dysfunction Varies from 10% to 16%
Symptomatic nonunion Difficult to treat In situ fixation or simple excision have
been advocated
Olecranon fracture
Relative uncommon, 5% of elbow fractures
20% to 50% associated with other elbow injuries Usually medial condyle
Treatment
Intra-articular fracture with step off > 2mm ORIF
Extra-articular fracture displacement > 5mm ORIF
Conservative treatment immobilization in about 20 degrees of flexion
Radial neck fracture
Cartilage radial head is resistant to fracture More radial neck fracture
About 50% of radial neck fractures are associated with other injuries to the elbow
Mechanism of injury
Fall onto a outstretched hand, with elbow in extension and valgus
Mechanism of injury
Fracture by impact against the inferior aspect of the capitellum at the time of dislocation or at the time of spontaneous reduction
Classification
O’Brien’s classification system
Treatment
Type I Simple immobilization for 1-2 weeks Close reduction if > 15 degrees (> 10
y/o)
Type II and III Close reduction Percutaneous or intramedullary
reduction
Treatment
Patterson technique
Treatment
Kaufman technique
Treatment
Wrapping technique
Treatment
Percutaneous reduction
Intramedullary reduction
Treatment
Open reduction Failed to achieve stable reduction with
closed reduction or minimal invasive techniques
Post reduction supination and pronation < 60 degrees
Radial head fracture complete displaced